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Get Out—and Don't Come Back

May 10, 2009
by daphne
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The last time my mom got out the hospital, she really had no idea what she was supposed to do. And of course she lost the instruction sheet they gave her.

Still, she was one of the lucky ones—she managed to stay out of the hospital. Too many patients are readmitted a week after their stay, when some simple follow up care could have prevented that readmission. We all know there’s something wrong with this picture.

Like most things, it comes down to the money.

When I was at HIMSS, it seemed there were a lot more people touting solutions like education modules, telehealth follows ups and monitoring. I started thinking about the rise of post discharge care as a trend. But here’s the question: Who’s paying?

Running these programs costs money, from the IT solutions to the nurses that monitor them. Again, who’s paying? Insurers typically don’t reimburse for the follow up. So not only are the hospitals spending money on providing the care, they’re losing the revenue of an expensive admission. Bad in good times, even worse in times like these.

I’ve seen firsthand that these solutions, particularly for chronic conditions like CHF, can improve lives and keep patients home. Years ago, I worked for a very highly rated heart hospital, with an amazing post-discharge follow up program, with an entire building devoted to post discharge care. BUT. This was one of the most heavily endowed hospitals in the country, with a stellar donor list and deep, deep coffers.

Sure, the program worked there. But you’re not that hospital, and you don’t have that kind of money.

There’s a little bit of panic starting about Washington’s buzz to reduce Medicare payments to hospitals with the highest re-admission rates. As many hospital administrators will say, “I can’t help it if they don’t take their medicine when they get home.”

But maybe it’s our job to make sure they do. Bundling payments by insurers to include post discharge care in a hospitalization would be a good place to start, I think.



Thanks for the comments! I just reread this and realized I wrote that Washington would reduce payments to hospitals with the highest discharge ratesI meant to write readmission rates. Highest discharge rates--now THAT would be interesting! Talking to some more people in this space today, and really looking forward to writing this story. I think it is really important, not only to drive down the cost of healthcare in this country, but, on a personal level, to keep patients like my mom from the misery of going back in.

Daphne, interesting post.

When I was running a medical service in PA, the Visiting Nurse Association (VNA) did a stellar job at identifying patients who would benefit from post-discharge follow-up and doing the follow-up.

So, based on my experience, I strongly agree with you. This is an important policy decision.

Incidentally, about four years ago, my hospital clients who frequently had patients from more than 50 miles away, started expressing interest in a patient portal, to make the lost discharge instructions electronically available. It was a common issue for patients to misplace those instructions. Anecdotally, it still is. And that, fortunately, is relatively inexpensive to fix.

Steve, you said it all in your first sentence. You are so right, and it is so clear those strategies need to be adjusted.

None of the current reimbursement strategies align incentives with what's best for patients. Fee for service incentivizes more service, single payer or managed care incentivizes less service, preventive care is often not covered because the future savings will not be realized by the current payer. We won't get what we don't pay for. Unfunded mandated care will drive away caregivers.
Steve Zeitzew, Orthopaedic Surgeon

Great post. You touch on two important areas: revising reimbursement and incentives to reward the care we want (that's the only way it will happen). And the issue of responsibility. We must be careful not to charge hospitals and physicians with tasks that are necessarily the responsibility of individuals. In some way, individuals must get hit in the pocketbook if they neglect or harm their own health, or don't take their medicine.